ICU Experience

Last day in Istanbul today! I'm back in Canada tomorrow. Not sure how I feel about that. It will be good to see people but I'm sad for the adventure to come to an end. I think I'd be more excited about returning to start residency. Somehow four more months of classwork just isn't appealing!

While finalizing other posts, I was reminded I hadn't written about my ICU experience! Here it goes.

ICU Experience

I spent 3 days in ICU at the end. It seemed to work essentially the way CTU at home does: meet quickly in the morning for handover, disperse and follow-up on patients, afternoon walking rounds with the attending. I haven't done a true ICU rotation at home, but from my surgical ICU experience this seemed quite different. Of note: the ICU attendings changed daily instead of weekly.

Cases were interesting: a 65% burn patient, a patient with unexplained muscle weakness (?ALS), a case of Naegleria fowleri, a couple traumas, a couple myasthena gravis crises (first presentation of myasthena gravis with respiratoryr distress), and several septic cases (perforated bowel, pneumonia, etc.). Unfortunately the septic patients nearly always succumbed.

One patient stood out for poor management. The initial diagnosis was brain trauma plus alcoholism (fell 10' onto his head while drunk). He had surgery appropriately and was recovering reasonably well after 10 days of ICU admission. When I was there he was diagnosed with delirium (for non medical: patient is essentially not himself. Could be aggressive, sleepy, self-harm, etc.). He was being managed with antipsychotics and physical restraints, despite the underlying cause not being investigated. The list of potential reasons for his delirium is long: direct result of the brain trauma, alcohol withdrawal (though 10days later), ventilator acquired pneumonia, catheter acquired UTI, disorientation secondary to ICU admission, etc. While the one ICU attending (Dr. Acharya of NCCDF) identified these and recommended  he be discharged to the floor for improved sensory stimulation etc., the others focused on medicating him with antipsychotics. It was heartbreaking to see a man that seemed quite with it struggling against physical restraints. (for non-medical: correct management of delirium is to treat any possible causes first, and then medicate only as a last resort).

* disclaimer: I wasn't sure about his mental status since I didn't see him at night, and couldn't talk to him. He seemed quite lucid, logically pleading with me through eyes and gestures for being released from his restraints.

Indian Wedding

While in Surat I had the opportunity to attend my friend Abhishek's wedding.

The wedding itself ran for 4 days total. Rough schedule was as follows:
Day 1 evening: groom hosts his extended family' plus bride's close family / friends for an evening of entertainment
Day 2 evening: bride hosts her extended family plus groom's close family / friends for an evening of entertainment
Day 3 morning: the groom goes through rituals in the presence of ladies (both sides of the family?). These include bribing him to take their food, lightening his skin, and lunch to him and his single male relatives / friends. Occurs at groom's house.
Day 3 evening: groom hosts bride plus single female relatives and friends for a meal they serve to the ladies
Day 4 lunch: bride hosts groom and male relatives / friends, serving them.
Day 4 evening: groom's family marches festively through the streets with a band, lights, fireworks, and dancing. Received by bride's family at hall with elaborate decorations. Some dancing at the receiving point, then inside for the rituals of marriage (can last up to 2.5hrs, historically up to 5 hrs). Given the length, these are intimate. People can observe, but generally mingle and eat instead.

Why so long? An Indian wedding forms the social life of the community. Friends, extended family, coworkers, neighbours etc. will all join in at least some of the festivities. It's a chance to relax with friends, and meet new people. For families with children of suitable age, the "parade of singles" is a chance to pursue potential matches. Events generally all revolved around socializing, food, music, and dance, in that order.

Venue for the first event with live band on stage.

Pavilion setup on the street in front of the house. It was used for a variety of events. Here the ladies of the community gather together with the mother of the groom to bemoan how horrible her future daughter-in-law will be. This happened concurrently with the first bride hosted main event.

Main venue

Parading through the streets

Elaborate entrance for receiving the groom and family on the last day

Food was initially scary as everything was in peanut oil. After that was resolved though (they switched to sunflower oil), I could actually eat most things. At the start the food was too spicy, but I grew used to it by the end (to the point that food initially was bland in Istanbul!).

For the final evening I acquired traditional Indian attire. I had funny looks throughout the week as the only non-Indian at the wedding. That was nothing compared to adding the Indian attire. I even was told I looked Indian :)

Overall I really enjoyed the wedding. It was great to see Abhishek's home, meet Krishna, and partake in the celebrations. One part was quite jarring: after the ceremony, it was time to send off the bride to join the husband's family. At a Western wedding, this is a happy occasion. Tears may be shed, but they are typically of joy or mixed emotions. The final send off of an Indian wedding is often sad and sombre, as the bride says farewell to her parents for what historically may be the last time. This certainly was not the case for Abhishek and Krishna, but they had the added stress that Krishna will eventually be moving to a foreign country far from home.

A great time in India! Thanks Abhishek and Krishna for inviting me to be part of your celebration.Looking forward to seeing you both back in Canada!

* I've deliberately kept photos of others off my blog. I'll post a photo of me and the couple if Abhishek gives the go ahead.

India

I left Kathmandu heading to Surat for a friend's wedding. I flew Spice Jet: they played Christmas music, and the flight attendants wore Santa hats for the Christmas Eve flight :). Along the way I connected in Delhi. At the suggestion of my friend, I restricted myself to luxury hotels for booking the airport hotel. I stayed at the Radisson Blu (5 star) and was super impressed. A level of service way beyond what I'm used to. Sadly I only had ~6hrs in the hotel each time.

Radisson Christmas morning

Surat is a giant city (metro pop 7million) and the 8th largest city in India. It's known for diamonds, food, and swearing apparently. I'm also guessing you've never heard of it before. It was certainly new to me when I was booking flights! Flights to Surat is another curiosity: it has only one or two flights a day total, despite its large population. Possibly because its close to Mumbai and Ahmedabad.

Once in Surat I spent evenings at the wedding activities, and tourism during the day. Except that there isn't a whole lot of tourism: places to go included the beach, science centre / museum, and mall. I did see the Indian Ocean though and there was a ridiculously ornate English cemetery. Felt just like Britain there...

Indian Ocean. I really wanted to wade in but there was a lot of mud to cross with low tide both times I came to this beach

Where am I again?

Ah, there's the oppulance of Empire. These are English tombs from 1600s. The basic graves from later are late 1800s.

It's worth adding a comparison between India and Nepal here. They share the same shops, crazy bike drivers, and general drive where there is room mentality. There is a sharp divergence in development though. India has smooth paved roads, highways, flyovers, modern buildings and malls. The electricity stays on and there is hot water. So too though is India much more unequal: for the first time on my trip I saw people living in tent slums. There were very poor dwellings in Nepal, but everyone seemed to have walls and a roof. This equality differences is borne out in the Gini coefficient (measure of inequality, 0=perfect equality with all income the same, 1=perfect inequality, one person has all the income). Nepal is 0.32, India 0.36. For reference Canada is 0.32.

Chitwan

Second half of my trip outside Kathmandu Valley was to Chitwan. Chitwan is a former royal hunting area, now a national park. It is known for jungle safaris, one horned rhinos, and royal Bengal tigers. Sounds great!

Having left Pokhara later in the day after a hike, we reached Chitwan late afternoon. Scenery along the way was spectacular.  Upon arrival it was quite cold and we sought a restaurant with "heat" (aka a fire!).

We followed this river most of the drive.

Just heading down the road on my elephant...

Mustard field. The entire crop is domestically consumed as mustard oil for cooking.

The next day was up to walk by the river and enjoy a relaxing tea :)

Peaceful scenery over tea

And a boatman. These boats are available to hire for going into the jungle. Other options are walking or elephant ride. I only had time for one so I went for elephant ride.

After lunch was a bike ride to the Elephant Breeding Grounds and a peaceful snack by the river. Unfortunately the elephants were in the park so we couldn't visit the breeding grounds. It was a great bike ride though!

Bridge to the elephant breeding grounds. What impressed me was it was made of bamboo, and would be underwater every monsoon season. Brown line to the right of the photo is high water level.

After returning the bikes, we headed to swim in the river. The water and air were both much warmer than Pokhara and I ended up swimming across twice :)

Evening was dinner while watching English Premiere League (at least until the electricity cut out).

Morning of the final trip was an elephant safari! It was great fun though quite bumpy on the elephant. I'll let the photos tell the story :) after the safari it was the end of the adventure and back to Kathmandu.

We sit in the basket, 4 people / elephant

Poor quality photo, but gives appreciation for how to get on an elephant

One horned rhino with baby. Only native to this part of the world.

Deer

Pokhara

First stop on adventures outside the Kathmandu Valley was Pokhara. Pokhara is a curious place - a quaint touristy area in Lakeside, but a metro area of 1 million people. We stayed in Lakeside and spent most of our time there.

The trip to Pokhara was an adventure for me used to Canadian roads. With the mountainous terrain, crazy traffic, and the often poor road quality a 200km journey became a day long adventure. Total transit time was actually ~5hrs but we stopped multiple times for tea or lunch. Lunch was in a gorgeous valley by the river and across from the only cable car in Nepal. It was overcast though so we didn't bother going up.

There's green valleys!

Our car.

Once in Pokhara we checked in to our hotel in the Lakeside area and headed out to wander around. Lakeside is primarily centred around the main road parallel to the lake. Here there are shops and restaurants of all varieties, mainly geared towards tourists. It felt a bit like Banff with a Nepali flair. For dinner I wanted variety and ordered pork western style. It was the only time I encountered significant challenges with allergies in Nepal. Go figure.

The next day we visited local temples, and explored some caves and a waterfall. Later in the day we went boating on the lake. Naturally I went swimming despite it being a bit cooler :) We stopped at a bar accessible only by boat and had tea / napped.

Waterfall. Apparently the water will flood the lower platform during monsoon season.

Boating! (after swimming)

Boats! :D

Christmas Tree! :D

The final morning in Pokhara we hiked up to the World Peace Pagoda, before heading out on a drive to Chitwan. Along the way we dropped off the inaugural issue of the NCCDF publication The ICU Post (see NCCDF blog post). Included in this was a stop at Manipal College of Medical Sciences where my anatomy professor formerly taught and Dr. Subhash Acharya, founder of NCCDF trained. I.e. the base of the connection that brought me to Nepal.

Side path. The trail actually had houses the whole way along. Going up we passed school kids walking down. Would be quite the daily climb!

World Peace Pagoda

Medical College

And campus. It's quite idyllic.